“New Choices” for substance‐using mothers and their children: Preliminary evaluation

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

Non-pharmacologic interventions to improve depression and anxiety among pregnant and parenting women who use substances: An integrative literature review

Pregnant and parenting women who use substances report high rates of comorbid depression and anxiety. Due to the significant impact of this comorbidity on treatment adherence and maternal/child outcomes, effective psychosocial and behavioral interventions to address depression and anxiety in this population are necessary. A directed search of PubMed, PsycINFO, and CINAHL databases produced 22 articles from 20 distinct studies examining non-pharmacologic interventions with an effect on depression and anxiety among pregnant or parenting women using substances. Of the 20 studies reviewed, 8 were randomized controlled trials, 7 were quasi-experimental studies, and 5 were cohort studies. Results revealed a wide array of interventions targeting intrapersonal, interpersonal, and/or structural factors within these women's lives. Parenting therapy and psychosocially enhanced treatment programs had the strongest evidence for positive treatment effect in improving symptoms of depression and anxiety. The use of contingency-management, case-managed care, patient or wellness navigators, mindfulness-based therapy, maternal-child relationship-focused therapy, family therapy, peer support, and therapeutic community-based interventions show promise but warrant further experimental exploration. Comprehensive and gender-specific residential treatment was observationally associated with improvements in depression and anxiety; however, the specific modality of efficacy is unclear. Future research should focus on identifying which modalities are most cost-effective, feasible, and acceptable among this uniquely vulnerable population.

A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases

Transportation is an important social determinant of health. Transportation barriers disproportionately affect the most vulnerable groups of society who carry the highest burden of chronic diseases; therefore, it is critical to identify interventions that improve access to transportation. We synthesized evidence concerning the types and impact of interventions that address transportation to chronic care management. A systematic literature search of peer-reviewed studies that include an intervention with a transportation component was performed using three electronic databases-PubMed, EMBASE, and CINAHL-along with a hand-search. We screened 478 unique titles and abstracts. Two reviewers independently evaluated 41 full-text articles and 10 studies met eligibility criteria for inclusion. The transportation interventions included one or more of the following: providing bus passes (n = 5), taxi/transport vouchers or reimbursement (n = 3), arranging or connecting participants to transportation (n = 2), and a free shuttle service (n = 1). Transportation support was offered within multi-component interventions including counseling, care coordination, education, financial incentives, motivational interviewing, and navigation assistance. Community health/outreach workers (n = 3), nurses (n = 3), and research or clinic staff (n = 3) were the most common interventionists. Studies reported improvements in cancer screening rates, chronic disease management, hospital utilization, linkage and follow up to care, and maternal empathy. Overall, transportation is a well-documented barrier to engaging in chronic care among vulnerable populations. We found evidence suggesting transportation services offered in combination with other tailored services improves patient health outcomes; however, future research is warranted to examine the separate impact of transportation interventions that are tested within multi-component studies.

Community networks of services for pregnant and parenting women with problematic substance use

Integrated treatment programs for pregnant and parenting women who use substances operate at the intersection of multiple service systems, including specialized substance use services, the broader health system, child protection, and social services. Our objectives were to describe the composition and structure of community care networks surrounding integrated treatment programs in selected communities in Ontario, Canada. We used a two-stage snowball method to collect network data from 5 purposively selected integrated treatment programs in communities in Ontario. Front-line staff with integrated treatment programs identified their top 5 service partners, who were then contacted and asked to provide the same information (n = 30). We used social network analysis to measure the cohesiveness, reciprocity, and betweenness centrality in the integrated treatment program’s ego network. We described network composition in terms of representation of different service types. Across communities, common service partners were child protection, substance use or mental health services, parenting and child support, and other social services. Primary and pre-natal care, opioid agonist therapy, and legal services were rarely named as partners. Networks varied in network cohesiveness, as indicated by connectivity between the service partners and reciprocal ties to the integrated treatment programs. Integrated treatment programs commonly brokered the connections between other service partners. Findings suggest that these integrated treatment programs have achieved a level of success in developing cross-sectoral partnerships, with child protection services, parenting and child support, and social services featuring prominently in the networks. In contrast, there was a lack of close connections with physician-based services, highlighting a potential target for future quality improvement initiatives in this sector.

Parenting outcomes of parenting interventions in integrated substance-use treatment programs: A systematic review

The high prevalence of women in substance use treatment programs with children, and the co-occurring negative physical and mental health outcomes associated with substance use, led to the development of integrated substance use treatment programs that target a range of women-specific issues. Integrated programs typically offer some type of parenting component, although the level of parenting services varies widely. Existing reviews have found positive child and parent outcomes following integrated treatment programs in general, although studies were not selected on the basis of whether they included parenting interventions. Due to the large percentage of substance using parents and research that parenting interventions contribute to decreased maternal substance use, this critical review examines parental outcomes of published studies on integrated programs that specifically include a parenting intervention component, as well as moderators of parenting and parental substance use/relapse. Across the 15 studies identified, this systematic review primarily focused on 8 parenting outcomes, including program retention, substance use, parenting stress, psychosocial adjustment, depression, child abuse potential, parenting behaviors, and parent-child interaction; as well as 5 additional secondary outcomes. The review discusses results on each of these outcomes, as well as retention rates across the parenting interventions.

Interventions to address parenting and parental substance abuse: conceptual and methodological considerations

Parental substance abuse is a serious problem affecting the well-being of children and families. The co-occurrence of parental substance abuse and problematic parenting is recognized as a major public health concern. This review focuses on 21 outcome studies that tested dual treatment of substance abuse and parenting. A summary of theoretical conceptualizations of the connections between substance abuse and parenting provides a backdrop for the review. Outcomes of the dual treatment studies were generally positive with respect to reduction of parental substance use and improvement of parenting. Research in this area varied in methodological rigor and needs to overcome challenges regarding design issues, sampling frame, and complexities inherent in such a high-risk population. This area of work can be strengthened by randomized controlled trials, use of mixed-methods outcome measures, consideration of parent involvement with child protective services, involvement of significant others in treatment, provision of concrete supports for treatment attendance and facilitative public policies.

Integrated programs for mothers with substance abuse issues and their children: a systematic review of studies reporting on child outcomes

BACKGROUND

Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children.

OBJECTIVES

To examine the impact and effects of integrated programs for women with substance abuse issues and their children, we performed a systematic review of studies published from 1990 to 2011.

METHODS

Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline; the treatment program included at least 1 specific substance use treatment and at least 1 parenting or child treatment service; the study design was randomized, quasi-experimental, or cohort; and there were quantitative data on child outcomes. We summarized data on child development, growth, and emotional and behavioral outcomes.

RESULTS

Thirteen studies (2 randomized trials, 3 quasi-experimental studies, 8 cohort studies; N=775 children) were included in the review. Most studies using pre-post design indicated improvements in child development (with small to large effects, ds=0.007-1.132) and emotional and behavioral functioning (with most available effect sizes being large, ds=0.652-1.132). Comparison group studies revealed higher scores for infants of women in integrated programs than those not in treatment, with regard to development and most growth parameters (length, weight, and head circumference; with all available effect sizes being large, ds=1.16-2.48). In studies comparing integrated to non-integrated programs, most improvements in emotional and behavioral functioning favored integrated programs and, where available, most effect sizes indicated that this advantage was small (ds=0.22-0.45).

CONCLUSIONS

Available evidence supports integrated programs, as findings suggest that they are associated with improvements in child development, growth, and emotional and behavioral functioning. More research is required comparing integrated to non-integrated programs. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of children of women with substance abuse issues.

Maternal substance use and integrated treatment programs for women with substance abuse issues and their children: a meta-analysis

BACKGROUND

The rate of women with substance abuse issues is increasing. Women present with a unique constellation of risk factors and presenting needs, which may include specific needs in their role as mothers. Numerous integrated programs (those with substance use treatment and pregnancy, parenting, or child services) have been developed to specifically meet the needs of pregnant and parenting women with substance abuse issues. This synthesis and meta-analysis reviews research in this important and growing area of treatment.

METHODS

We searched PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL and compiled a database of 21 studies (2 randomized trials, 9 quasi-experimental studies, 10 cohort studies) of integrated programs published between 1990 and 2007 with outcome data on maternal substance use. Data were summarized and where possible, meta-analyses were performed, using standardized mean differences (d) effect size estimates.

RESULTS

In the two studies comparing integrated programs to no treatment, effect sizes for urine toxicology and percent using substances significantly favored integrated programs and ranged from 0.18 to 1.41. Studies examining changes in maternal substance use from beginning to end of treatment were statistically significant and medium sized. More specifically, in the five studies measuring severity of drug and alcohol use, the average effect sizes were 0.64 and 0.40, respectively. In the four cohort studies of days of use, the average effect size was 0.52. Of studies comparing integrated to non-integrated programs, four studies assessed urine toxicology and two assessed self-reported abstinence. Overall effect sizes for each measure were not statistically significant (d = -0.09 and 0.22, respectively).

CONCLUSIONS

Findings suggest that integrated programs are effective in reducing maternal substance use. However, integrated programs were not significantly more effective than non-integrated programs. Policy implications are discussed with specific attention to the need for funding of high quality randomized control trials and improved reporting practices.

Services used by perinatal substance-users with child welfare involvement: a descriptive study

Background

Substance use during pregnancy often leads to involvement in the child welfare system, resulting in multiple social service systems and service providers working with families to achieve successful child welfare outcomes. The Vulnerable Infants Program of Rhode Island (VIP-RI) is a care coordination program developed to work with perinatal substance-users to optimize opportunities for reunification and promote permanency for substance-exposed infants. This paper describes services used by VIP-RI participants and child welfare outcomes.

Methods

Data collected during the first four years of VIP-RI were used to identify characteristics of program participants, services received, and child welfare outcomes: closed child welfare cases, reunification with biological mothers and identified infant permanent placements.

Descriptive Results

Medical and financial services were associated with positive child welfare outcomes. Medical services included family planning, pre- and post-natal care and HIV test counseling. Financial services included assistance with obtaining entitlement benefits and receiving tangible support such as food and clothing.

Conclusions

Findings from this study suggest services that address basic family needs were related to positive child welfare outcomes. The provision of basic services, such as health care and financial assistance through entitlement benefits and tangible donations, may help to establish a foundation so mothers can concentrate on recovery and parenting skills. Identification of services for perinatal substance users that are associated with more successful child welfare outcomes has implications for the child welfare system, treatment providers, courts and families.

Treatment Issues for Aboriginal Mothers with Substance Use Problems and Their Children

In many cultures, approximately one third of people with drug dependence are women of child-bearing age. Substance use among pregnant and parenting women is a major public health concern. Aboriginal people have some of the highest rates of substance abuse in Canada, increasing concern for detrimental health impacts, including those for women and their children. For many women, substance abuse offers a means of coping with trauma, such as childhood abuse, partner violence, and, for Aboriginal women, the intergenerational effects of colonization. In this paper, we review treatment issues for Aboriginal mothers with substance use problems and their children. We discuss gender-specific issues in substance abuse, the need for women-specific treatment, the impact of substance abuse on children and parenting, the additional risks for Aboriginal women and children, and the need for integrated programs (those that integrate pregnancy-, parenting-, and child-related services with women-specific addiction treatment). We describe New Choices as an example of an integrated program, review research on existing treatment for Aboriginal mothers with substance use issues, and describe Sheway as a promising integrated program for Aboriginal women with substance abuse issues and their young children. There are few treatment programs specifically for Aboriginal mothers with substance use issues and their children and very little research on their effectiveness. Based on our review of existing evidence, we offer recommendations for future research and practice.

Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management

Exposure to alcohol in utero is considered to be the leading cause of developmental disabilities of known etiology. The most severe consequence of such exposure, fetal alcohol syndrome (FAS), is characterized by a distinct constellation of characteristic facial anomalies, growth retardation, and central nervous system (CNS) dysfunction. Some individuals with prenatal alcohol exposure (PAE) do not meet the full criteria for FAS, but instead are diagnosed with partial FAS, alcohol related neurodevelopmental disorder (ARND), or alcohol related birth defects (ARBD). The entire continuum of effects from PAE is increasingly being referred to under the umbrella term of fetal alcohol spectrum disorders (FASDs). An extensive body of research has documented major cognitive, behavioral, adaptive, social, and emotional impairments among individuals with FASDs. Although FAS was identified in the U.S. over 35 years ago, the development, evaluation, and dissemination of evidence-based interventions for individuals with FASDs have lagged behind significantly. Encouragingly, however, in recent years there has been a marked increase in efforts to design and test interventions to remediate the impairments associated with prenatal alcohol exposure. This article will review treatment needs and considerations for individuals with FASDs and their families, current empirically tested treatment approaches, case management issues, and suggestions for future directions in research on the treatment of FASDs.